The primary survey

The purpose of the primary survey is to rapidly identify and manage impending or actual life threats to the patient.  

Introduction

Always assume all major trauma patients have an injured spine and maintain spinal immobilisation until spine is cleared.

Priorities are the assessment and management of:

• c          Catastrophic haemorrhage
• A          Airway (and C-spine control)
• B          Breathing
• C          Circulation
• D          Disability
• E          Exposure / Environment

Prior to arrival:

• Activate Trauma Team (as per Trauma Team Activation criteria).
• Pre-arrival briefing for team with synthesis
• Use of Pre-arrival checklist to help with role and task allocation
• Estimate the child's weight using the formula:
• Prepare age / weight appropriate doses of medication (use the Monash Drug book or other similar resource)
• Prepare age appropriate equipment
• Ensure personal protective equipment and lead aprons are worn by the trauma team

On arrival:

• Obtain a I-MIST-AMBO handover from ambulance staff
• Perform a primary survey
• Obtain further information from parents / caregivers where possible
• Ensure a dedicated member of staff is available to provide support for parents / caregivers

Airway and the cervical spine

The life threat to identify and manage when assessing the Airway is airway obstruction

This is typically the responsibility of the "Airway Doctor" although it is a role which may be shared with the "Assessment Doctor".   The Airway Doctor is typically responsible for assessing the airway, the anterior neck and the GCS. Their goal is to ensure and maintain a patent airway, through which the patient can be successfully oxygenated.

When assessing the airway.  The airway doctor should start with assessing for:

• Evidence of facial fractures
• Contaminants such as blood, vomit or teeth in the mouth / airway
• Epistaxis

Where the patient has suffered a burn, the airway doctor should look in particular for:

• Singing of facial / nasal hair
• Facial burns
• Hoarseness or change in voice
• Harsh cough
• head or neck swelling
• Soot in the mouth, nose or saliva

A complete airway assessment also requires an assessment of the anterior neck - looking in particular for signs of blunt or penetrating trauma, or an impending airway life threat.  This requires the airway doctor to open the C-spine collar whilst an assistant maintains manual in-line stabilization of the cervical spine.  The Airway doctor should then examine the anterior neck to look / feel for the following (TWELVE-C):

• Tracheal deviation
• Wounds
• Emphysema (subcutaneous)
• Laryngeal tenderness / crepitus
• Venous distension
• oEsophageal injury (injury unlikely if able to swallow easily)
• Carotid haematoma / bruits / swelling

The airway doctor also needs to assess the GCS

The life threat to identify  when assessing the Airway is airway obstruction.  Causes of airway obstruction may be due to:

• Direct trauma to the airway or surrounding structures (maxilo-facial / laryngeal / tracheal injury / compression due to anterior neck haematoma)
• Contamination of the airway due to debris (vomitus / blood / teeth or other foreign bodies)
• Loss of pharygeal tone (due to head injury or intoxication with drugs/alcohol)
• Incorrect positioning (hyperflexion of the infant due to their large occiput)

The management of airway obstruction is to ensure a patent airway through which the patient can effectively be oxygenated.  This may require some or all of the following techniques:

•  Age appropriate positioning of the head into a neutral position (utilising a thoracic elevation device if <8yrs old or a towel under the shoulder blades to provide thoracic elevation)
• Gentle suction of the airway to remove blood / vomitus / secretions
•  Application of high flow oxygen
• Jaw thrust - avoiding head-tilt or chin lift
• Use of an oropharyngeal airway if tolerated, or naso-pharygeal airway (if head injury is excluded / unlikely)
• Intubation - by an experienced operator

The cervical spine should be protected by manual in-line stabilisation, followed by the rapid (gentle) application of a properly fitted hard collar.  (see cervical spine assessment clinical practice guideline)

Breathing

The life threats to identify and manage with regards to breathing include:

• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest

The assessment of breathing, in the spontaneously ventilating child, is the responsibility of the assessment doctor.  Where a child requires positive pressure ventilation (either bag-valve-mask ventilation, or intubated) there will be a shared responsibility for the assessment of breathing by the airway and the assessment doctors.  At the start of the assessment,  ensure all patients who are spontaneously breathing have high flow oxygen applied – typically 10-15L O₂ via a non-rebreather mask.  The child’s breathing is then assessed by looking at:

• The work of breathing (recession, respiratory rate, accessory muscle use)
• The effectiveness of breathing (oxygen saturation, symmetry and degree of chest expansion)
• The effects of inadequate respiration (heart rate, mental state)
• Signs of injury (seat belt marks, bruising, wounds)

Assessment of the thoracic cage requires feeling for:

• Emphysema / crepitus
• Clavicle / chest wall tenderness
• Request a chest X-ray – this is an important addition to the primary survey

Assessment also requires listening for:

• Breath sounds or added sounds

The life threats to identify with regards to breathing include:

• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest

The management of these life threats is typically carried out by the procedure doctor under direction from the Team Leader.  Once a life threat has been identified, the assessment doctor should communicate this to the Team Leader, and then continue on with the primary survey allowing the procedure doctor to carry out any interventions.  Typical interventions include:

• Chest decompression (by needle decompression / finger thoracostomy) for a tension pneumothorax - followed immediately by insertion of a chest drain
• Chest drain insertion for a massive hameothorax
• Closure of an open pneumothorax, and insertion of a chest drain
• Positive pressure ventilation and insertion of a chest drain for a flail chest.

Intubated children may also benefit from the early insertion of a large oro-gastric tube to treat and prevent gastric dilatation which in infants and young children especially, can impair effective ventilation.

Circulation

The major life threat to identify and manage with regards to circulation is haemorrhagic shock.  However, obstructive shock does also occur, and causes for this should also be actively sought and managed.

The assessment of the circulation is the responsibility of the “Assessment” Doctor.  They should assess the child’s circulatory state by:

• checking the pulse rate, skin colour, capillary refill time, blood pressure
• looking for other effects of an inadequate circulation (increased respiratory rate, decreased mental state).

It is useful for the assessment doctor to calling out the patients vital signs at this stage of the assessment - so the team is aware of them.  The assessment doctor should continue with a focused assessment that involves looking for sites of potential bleeding.  These include the following sites:

• External bleeding – assess by exposing wounds and look for ongoing bleeding - do not remove penetrating foreign bodies
• Intra-thoracic bleeding – assess for massive haemothorax (as per breathing above)
• Intra-abdominal bleeding – inspect for abdominal distension, bruising, and palpation for tenderness / guarding
• Intra-pelvic bleeding – gently assess the pelvis for stability by by compressing the iliac crests
• Long bone fractures – in particular assess the femurs as a site for major bleeding
• Retroperitoneal bleeding – this can be hard to identify – but maintain a high level of suspicion in those with signs of haemorrhagic shock and no obvious signs of bleeding elsewhere or flank tenderness

The assessment doctor should, in consultation with the Trauma Team Leader, consider the need for a pelvic x-ray (see also Pelvic Injury CPG).  

The major life threat to identify with regards to circulation is haemorrhagic shock

However, care should be taken to actively look and exclude:

• obstructive cause for shock - for example tension pneumothorax or cardiac tamponade)
• neurogenic shock - associated with spinal injury above the level of T6

The management of haemorrhagic shock is to identify and stop the source(s) of bleeding whilst concurrently resuscitating the patient.  The management of these life threats may need multiple team members and is co-ordinated by the Trauma Team Leader.  Once the assessment doctor has identified these life threats, they must communicate their findings to the Trauma Team Leader, then continue with the primary survey.  The management of haemorrhagic shock may include:

• In external haemorrhage bleeding may be stopped through the use of direct pressure, or in some cases the judicious use of a tourniquet.
• Inserting a chest drain into a patient with a massive haemothorax may improve ventilation, but stopping ongoing bleeding can only be done in theatre.
• Similarly life threatening bleeding into the abdomen / pelvis or  retroperitoneum that is not otherwise controlled will require surgery or interventional radiology to stop the bleeding.  Early consultation with a senior paediatric surgeon +/- an interventional radiologist is required.  Rapid transit to theatre, prior to completion of the secondary survey, may be required to manage patients with ongoing bleeding that cannot be controlled in the emergency department. 
• Application of the pelvic binder is a haemostatic adjunct
• Bleeding from bone fractures may be reduced through traction
• Resuscitation of shock requires intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital fossa.
  • If an IV cannula cannot be sited rapidly (within 90 seconds), consider the use of an intra-osseous needle inserted into a non-traumatised leg or humerus in the older child.
  • As the IV is inserted, take blood for a VBG, FBE, cross-match, UEC, LFTs, lipase and coagulation screen
  • If circulation is inadequate, give an initial fluid bolus.  If there is ongoing bleeding this may be packed red blood cells (10ml/kg), if bleeding is controlled and blood loss is not thought to be major, you may opt to give of 10-20 ml/kg of crystalloid however care needs to be given to avoid contributing to coagulopathy, acidosis and hypothermia that can occur with excessive crystalloid  administration

Assess the child's circulatory state by observing:

1. pulse rate, skin colour, capillary refill time, blood pressure;
2. the effects of an inadequate circulation (respiratory rate, mental state).

• Establish intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital fossa.
• If an IV cannula cannot be sited rapidly, consider the use of an intra-osseous needle inserted into a non-traumatised leg.
• As the IV is inserted, take blood for a blood sugar, FBE, cross-match.
• If circulation is inadequate, give a fluid bolus of 20 ml/kg of normal saline.
• Tamponade any continuing external haemorrhage.
• If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a colloid solution. If a third bolus is necessary, consider using packed cells (O negative, group-specific or cross-matched, as available), and arrange early surgical intervention

Disability (mental state)

The life threat to identify is traumatic brain injury

The assessment of 'Disability' is typically the responsibility of the airway doctor - although the assessment doctor may add and complement to this by assessing peripheral function.  Initial assessment of the level of consciousness may be done using the AVPU assessment:

• A = Alert
• V = responds to Voice
• P = responds to Pain
• U = Unresponsive

Any impairment on detected on the AVPU scale should prompt a formal assessment of the patient’s GCS (link to GCS-level of consciousness in Head Injury CPG).  Pupil response to light should be noted, as should movement in all four limbs.  The assessment doctor should check for this as well as reflexes if the prior to intubation where possible.  The blood glucose level should be measured on arrival and periodically during the management of the trauma patient.

The life threat to identify is traumatic brain injury - whilst the primary brain injury cannot be reversed, secondary brain injury can be minimised by the prevention of hypoxia/hypotension and instigation of neuroprotective strategies to minimise intracranial pressure, along with the expedited progress of the patient to CT imaging of the brain, and then to a site capable of any necessary neurosurgical intervention.

Exposure and environmental control

Remove clothing initially and look for any other obvious life threatening injury.  Avoid hypothermia by limiting exposure of the body, and by warming all ongoing fluids.  

Radiology 

• Arrange for chest to be done in the resuscitation room as part of the primary survey.  
• Pelvic injury is rare in children, the pelvic x-ray does not always need to be requested in paediatric trauma.  However, it is done where there are risk factors for pelvic injury and the patient is unlikely to need CT imaging of the abdomen and pelvis.  The risk factors for pelvic injury include:
  • high risk mechanisms - these include:
    • high speed / rollover or lateral impact motor vehicle accidents
    • Pedestrian vs car
    • Cyclist vs car
    • MVA where another person has died
  • Abnormal pelvis examination
  • Significant lower limb injury (eg femur fracture)
  • Intubated or unable to assess pelvis
• If there is no high risk mechanism, no clinical suspicion of a pelvic injury AND the child is haemodynamically stable withhas a normal conscious state, the pelvic X-ray may be omitted.
• Arrange additional radiology as indicated 
  

References

1. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
2. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
3. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
4. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: Prompt identification and early management of serious life-threatening injuries. Part 1: injury patterns and initial assessment. Paediatric Emergency Care 2000;16:106-115.
5. Royal Children's Hospital Melbourne. Clinical Practice Guidelines

-Trauma (Major)

Secondary survey

Introduction

The secondary survey is commenced after the primary survey has been completed, immediate life threats identified and managed, and the child is stable. Continue to monitor the child’s:

• Mental state
• Airway, respiratory rate, oxygen saturation
• Heart rate, blood pressure, capillary refill time.

Any unexpected deterioration in these parameters require reassessment and management of evolving life threats.

Preparation:

Before commencing the examination:

• develop a rapport with the child, offer reassurance and explain what you are doing
• involve the parents or other adults accompanying the child by telling them what you are doing and using them to comfort or distract the child
• keep the child warm and - as far as possible - covered
• remove clothing judiciously - a full examination is necessary, but ensure the child is covered up following examination

Performing the examination:

Head and face

Inspect the face and scalp. Look for:

• Bleeding,  lacerations, bruising, depressions or irregularities in the skull, Battles sign (bruising behind the ear indicative of a base of skull fracture). 
  

Look specifically at the:

• Eyes: for foreign bodies, subconjunctival haemmorhage, hyphaema, irregular iris, penetrating injury, contact lenses.
• Ears: for bleeding, blood behind tympanic membrane (suggestive of base of skull fracture)
• Nose: for deformities, bleeding, nasal septal haematoma, CSF leak
• Mouth: for lacerations to the lips, gums, tongue or palate.
• Teeth: for subluxed, loose, missing or fractured teeth
• Jaw: for pain, trismus, malocclusion suggestive of fracture.

Palpate the:

• bony margins of the orbit, the maxilla, the nose and jaw.
• the scalp / skull looking for evidence of fracture 

Test eye movements, pupillary reflexes, vision and hearing 

Neck

Inspect the neck - it is necessary to open the collar to do this - whilst maintaining manual in-line stabilisation of the neck. Examine the anterior neck (as per the primary survey) checking for:

• tracheal deviation
• wounds / bruising to the neck
• subcutaneous emphysema
• laryngeal tenderness
• distension of the neck veins
• carotid pulsation and the presence of a haematoma, listen for a bruit

Asses the c-spine by palpation of the cervical vertebrae (see Cervical spine assessment CPG)

Chest

Inspect the chest, observe the chest movements.  Look in particular for:

• bruising (from seat-belts)
• asymmetric or paradoxical chest wall movement
• penetrating wounds are rare in children, but in cases where there is a stabbing or other assault look for "hidden" wounds - checking areas such as the axilla and back

Palpate for clavicular and rib tenderness and auscultate the lung fields and heart sounds. 

Abdomen

Inspect the abdomen, the perineum and external genitalia.  Look for in particular for:

• seat-belt bruising / handle-bar injuries
• distension
• blood at the urinary meatus / introitus

Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds.       

Pelvis

Inspect the pelvis for grazes over the iliac crest.  Examine for bruising, deformity, pain or crepitus on movement. 

Limbs

Inspect all the limbs and joints, palpate for bony and soft tissue tenderness and check joint movements, stability and muscular power.  Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Back

A log roll should be performed either in the primary survey or in the secondary survey.  

• Inspect the entire length of the back and buttocks.
• Palpate, then percuss, the spine for tenderness,
• Palpate the scapulae and sacroiliac joints for tenderness
• Inspect the anus. Digital examination is rarely needed – if it is indicated it should only be performed once.

Urinalysis

Interpretation of the urine dipstick in blunt paediatric trauma suffers from high rates of false positive and false negative results – formal microscopy is the better test where renal injury is suspected.

Disposition planning

During the examination, any injuries detected should be accurately documented, and any urgent treatment required should occur, such as covering wounds and splinting fractures.  Appropriate analgesia, antibiotics or tetanus immunisation should be ordered.  Following the secondary survey, the priorities for further investigation and treatment may now be considered and a plan for definitive care established.  At this stage the patient may require advanced imaging in CT, or transfer to the ward, intensive care or theatre.

Typically the trauma team leader will remain responsible for the patient until they have completed their imaging and arrived at their inpatient destination.  Handover of care may occur sooner than this – for example if the anaesthetist is present in the ED and will accompany the patient to theatre or intensive care.  On these occasions formal handover where the new team leader and team acknowledge that  responsibility for the patient has been transferred.  A departure checklist made aid in this process.

References

1. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
2. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
3. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
4. Royal Children's Hospital Melbourne. Clinical Practice Guidelines

-Trauma (Major)